The saying "Everything is Bigger in Texas," is no exaggeration.

In terms of area, the only state bigger than Texas is Alaska. At roughly 268,820 square miles, the Lone Star State could engulf the entire northeastern part of the country and then some.

Yet, with great size comes great frustration, especially when it comes to Texas' unique incarceration situation. With the largest prison population in the nation, Texas' approximately 154,000 prisoners are housed in 111 facilities, many of which are located in remote rural areas, spread across the entire state.

Factor in the reality that prisoners, like most of us, are living longer and costing more from a care perspective, and you don't have to be a mathematician to recognize that this presents a bit of a conundrum. How can you effectively provide comprehensive care for that many prisoners, housed in remote locations, in an efficient, cost-effective manner?

Leaders of the Texas Department of Criminal Justice turned to telemedicine. Since its inception in 1994, the prison telemedicine program, outsourced to both the University of Texas Medical Branch (UTMB) in Galveston and Texas Tech University Health Sciences Center in Lubbock, has facilitated countless medical examinations and consultations in Texas prisons and the associated prison hospital in Galveston, leading to impressive clinical and financial results.

According to a Gartner study, the telemedicine program has led to nearly $1 billion in savings over a 10-year period, while cutting back emergency rooms and doctor office visits by 70 percent and unnecessary medical tests by 45 percent. It has significantly cut back on prison transports, which are expensive and dangerous, and weeded out the pretenders, offenders who are exaggerating or faking an illness or injury.

Yet, according to Mickey Bourdeau, Director of Technical Operations for Correctional Managed Care at UTMB, the program has done more than that. "From a continuity of care standpoint, [telemedicine] has allowed us to see patients continually, draw on specialists, and beam those specialists into remote prisons where there is no specialty care," says Bourdeau, who oversees the telemedicine operations in UTMB’s Correctional Managed Care program.

The telemedicine program in action Credit: UTMB

Comprehensive, Coordinated Care

The telemedicine program at UTMB began with private T1 data circuits, connecting providers and patients miles apart across the state of Texas, back in an era where most people had dial-up internet. Over time, the cost for the networks has reduced dramatically, from $1.2 million per year to $600 thousand, and the technology has obviously improved.  

The ideals have stayed the same. The prison telemedicine program is used to provide offenders with comprehensive care in an economical manner. It's not just meant for screenings, although primary care is definitely a focus. However, the program also includes mental health screenings, hepatitis C screenings, orthopedic and urology care, and pain management.

"We use it for a lot of things. A lot is mental health and medication management. In addition to primary care, there are probably 10-15 specialties that we do for pre or post-follow-ups," Bourdeau says.

In addition, Bourdeau explains that the telemedicine system is linked to an electronic medical record (EMR) system, which documents the complete patient medical chart information including lab results and physician notes. The EMR is also linked to a primary care specialty scheduling template, which is also linked to the telemedicine room. Overall, it allows for easier patient care coordination.  Scheduling in general is one of the challenges of the telemedicine program, Bourdeau says.

"Figuring out how to schedule these examinations, with the doctors, with security, the patient, room equipment and everything else is tough. The EMR scheduling process that we set up helps and controls that," Bourdeau says.

Mickey Bourdeau Credit: UTMB

Finding Telemedicine Docs

Another challenge UTMB has encountered with the prison telemedicine program is finding doctors who are willing and able to, as Bourdeau puts it, "sit at a desk all day in front of equipment and beam from patient to patient." It's not exactly how many doctors envisioned practicing medicine when they began their careers.

One thing the organization has done is move closer to large metropolises. "We've put our [telemedicine] hubs near heavy population areas, where there are a lot of providers," Bourdeau says. "Before that, it was hard to recruit providers."

The organization has also worked to solve this issue by recruiting retired doctors and specialists who want to practice part-time, on top of the dedicated full-time staff it employs.

Over time, Bourdeau says the telemedicine program will continue to improve, especially when it comes to efficiency of care. Even with the EMR in place, he says there are still gaps when it comes to scheduling and ordering and receiving lab tests. Adding to this challenge is that the limitations of prison have made newer technologies, such as mobile monitoring and alerts, unavailable for use. However, he says that should eventually change too.

Naturally, there are skeptics, those who contend that telemedicine cannot effectively care for a patient. To those people, Bourdeau and others could just point to the results of the Texas prison program and let that speak for itself. They could talk of other large states, California and Arizona, which have also found (albeit smaller) successes in similar programs. Yet to those doubters, including some on the Texas Medical Board, Bourdeau says what they should know is that this technology is necessary.

"The reality is the shortage of providers is making it essential. It's another piece of the healthcare service toolset that this country and the world are starting to use to supplement care in larger populations, rural populations, with an insufficient number of practitioners that can't see all these patients," Bourdeau says.

In Texas, where people like to intone and brag about its overall size, telemedicine has been successful in shrinking down the state and improving care.